Parasomnias in children are common and may consist of abnormal movements, behaviours, emotions, and autonomic activity during transitions between sleep states, from sleep to wakefulness, or during arousals from sleep.
Non-rapid eye movement (NREM) parasomnias include sleepwalking, night terrors, and confusional arousals, that occur most commonly in the first half of the night.
Rapid eye movement (REM) parasomnias occur later during the night and consist of experiences such as nightmares, recurrent isolated sleep paralysis, and REM sleep behaviour disorder (RBD). The latter is extremely rare in children.
The three most common modifiable triggers for parasomnias in children include sleep deprivation, restless legs syndrome, and obstructive sleep apnoea. Treatment of these disorders may significantly reduce or resolve parasomnias in affected children.
Parasomnias are diagnosed on clinical grounds, based on descriptions from an observer, such as a parent or sibling who may share the bedroom. Ordinarily, a sleep study (diagnostic polysomnogram) is not necessary to establish the diagnosis. However, this test may be ordered when other comorbid primary sleep disorders, such as sleep apnoea, are suspected, and it is required for the diagnosis of RBD.
Management usually consists of treatment of the underlying cause of the parasomnia, reassurance, modification of the sleep environment, and, in adolescents, avoidance of substances such as caffeine and alcohol. When parasomnias become frequent and more problematic, occasionally pharmacological agents may be helpful.
The home environment needs to be modified to increase safety. This includes removal of any potentially dangerous items and sharp objects, locking doors, arranging for a sleeping space on the ground floor, and installation of door alarms.
Parasomnias are undesirable, non-deliberate motor or subjective phenomena that occur during the transition from one sleep state into another, from wakefulness into sleep, or during arousals from sleep.
They are ubiquitous among children and more frequent than in adults. Most paediatric parasomnias are benign, self-limited, and generally do not persist into adulthood.
Parasomnias are considered clinical disorders due to their consequences, which include injury, sleep disruption, adverse health effects, and negative psychosocial effects. They are not a unitary phenomenon but rather may result from a wide variety of conditions, most of which are readily diagnosable, treatable, and explainable.
Parasomnias may include abnormal movements, behaviours, emotions, and autonomic activity, and may be manifestations of central nervous system activation. This topic will cover confusional arousals, sleepwalking, sleep terrors, nightmares, isolated recurrent sleep paralysis, and rapid eye movement sleep behaviour disorder (RBD).
The term 'disorder of arousal' is used to imply incomplete arousal from non-rapid eye movement (NREM) sleep, manifesting with parasomnias. Confusional arousals are characterised by mental confusion or confused behaviour that occurs while the patient is in bed. There is an absence of terror or ambulation outside the bed. When the patient leaves the bed, this is classified as 'sleepwalking'.
History and exam
Key diagnostic factors
- presence of risk factors
- disturbed cognition during event (confusional arousals, sleep terrors, sleepwalking)
- vigorous activity or violent behaviour (confusional arousals, sleepwalking, sleep terrors, and rapid eye movement sleep behaviour disorder [RBD])
- episodes of inability to move (isolated recurrent sleep paralysis)
- autonomic hyperactivity during event (sleep terrors)
- normal physical examination between episodes
Other diagnostic factors
- abnormal demeanour and facial expression (confusional arousals, sleepwalking, sleep terrors)
- evidence of injuries
- family history of non-rapid eye movement (NREM) parasomnias (confusional arousals, sleepwalking, sleep terrors)
- presence of HLA gene DQB1*05 and *04 alleles (sleepwalking)
- medications or alcohol
- history of psychiatric disorder
- acute sleep deprivation or irregular sleep-wake schedule disorder
- emotional stress and traumatic life events
- forced awakenings
- untreated comorbid sleep disorders
- premenstrual state (in adolescent girls)
1st investigations to order
- clinical examination
- polysomnography (rapid eye movement sleep behaviour disorder)
Investigations to consider
- polysomnography (confusional arousals)
- polysomnography (sleepwalking)
- polysomnography (sleep terrors)
- polysomnography (nightmare disorder)
- polysomnography (all other parasomnias)
- polysomnography with expanded electroencephalogram (EEG) video recording
- urine drug screen
isolated recurrent sleep paralysis
rapid eye movement sleep behaviour disorder
Shalini Paruthi, MD
Co-Medical Director, Sleep Medicine and Research Center
St. Luke's Hospital
Adjunct Associate Professor
Department of Pediatrics
Saint Louis University School of Medicine
SP receives royalties from UpToDate for writing two topics: diagnosis and management of pediatric obstructive sleep apnea. SP is a board member of the Restless Legs Syndrome Foundation.
Dr Shalini Paruthi would like to gratefully acknowledge Dr Raman Malhotra and Dr Alon Y. Avidan, previous contributors to this topic.
AYA has been paid honorarium speaking fees by the American Academy of Sleep Medicine, the American Academy of Neurology, the American College of Chest Physicians, Sepracor Inc, Cephalon Inc, and Pfizer Pharmaceuticals.
Paul Gringras, MB, ChB, MSc, MRCPCH
Consultant in Paediatric Neurodisability
Evelina Children's Hospital
St Thomas' Hospital
PG is lead applicant on the ongoing MENDS trial, which is concerned with the use of melatonin in children with neurodevelopmental disorders and impaired sleep.
Paul Montgomery, MSc, DipSW, DPhil
Reader in Psycho-Social Intervention
Centre for Evidence Based Intervention
University of Oxford
PM has received funding greater than 6 figures USD from the Swedish Board of Health and Welfare, Martek Biosciences, Danish Social Research Institute, UK Department of Health, UK Health Technology Assessment Programme. PM declares that he has no competing interests.
Lynn A. D'Andrea, MD
Associate Professor of Pediatrics
Division of Pulmonary and Sleep Medicine
Department of Pediatrics
Medical College of Wisconsin
Children's Hospital of Wisconsin
LAD declares that she has no competing interests.
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